Invasive Aspergillosis of Nose and Paranasal Sinus in COVID-19 Convalescents: Mold Goes Viral?

Abstract

Invasive Aspergillosis of the paranasal sinus is an aggressive illness, particularly affecting the immunocompromised and rarely, the immunocompetent. COVID-19 has been shown to cause a derangement of immune parameters both during active infection and the convalescent period. A retrospective study was done from June 10th 2021 to September 10th 2021 on patients who underwent endoscopic debridement of the involved sinuses for post COVID fungal rhinosinusitis. This study included the patients who had Aspergillus infection from the isolated nasal tissue samples. Patient's information, complaints, history of COVID infection, clinical findings, investigations and treatment details were obtained from the records. 13 patients with post-COVID Invasive Fungal Sinusitis were identified. Symptom onset usually occurred within 1 month of COVID 19 diagnosis in all the patients. Nasal obstruction (84%) and headache (61%) were the most common symptoms. Computerized tomography imaging showed maxillary sinus involvement in all patients followed by ethmoid sinus in 76% of patients. Microbiological diagnosis and histopathological confirmation of Aspergillus species was done. All 13 patients underwent endoscopic debridement of the involved sinuses followed by anti-fungal therapy with Posaconazole. All responded well to the treatment with no recurrence till date. Admist an infinite number of Mucormycosis cases in this era of COVID-19 pandemic, we experienced a surge of Aspergillus infection during this second wave. Presentation at a young age, with no known co-morbidities, with minimal symptoms and history of COVID-19 infection are some of the important aspects to be considered in this series. A better morbidity outcome is expected when early detection and treatment is made in patients with post Covid-19 viral illness with Aspergillosis of nose and paranasal sinus.

COVID-19-associated fungal infections in Iran: A systematic review

“…CAPA is almost exclusive to ICU-admitted patients, while Aspergillus rhinosinusitis was reported in several outpatient COVID-19 cases [ 108 , 111 , 114 , 115 ]. All except one of the Iranian cases with available data were admitted to ICUs.…”

Aspergillus brain abscess presents as sinusitis in immunosuppressed and hyperglycemic patient

“…A very recent article, "Invasive Aspergillosis of nose and paranasal sinus in COVID-19 convalescents: Mold goes viral?," was published in January 2022 on post-COVID fungal infections of the nose and paranasal sinuses. The study stated that during the first wave of COVID-19, most post-COVID fungal infections seemed to be due to mucormycosis, however, invasive Aspergillus infections seemed to be rising in number during the second wave of COVID-19 [21]. Our patient tested negative for COVID-19 at presentation to the emergency department.…”

“…Compared to their study's patients, our patient did have underlying comorbidities (steroid treatment and uncontrolled T2DM) and therefore was significantly more predisposed to develop an invasive Aspergillus sinus infection after infection with COVID-19. COVID-19 virus is known to decrease CD8+ and CD4+ T cells which would further increase the susceptibility of post-COVID patients to developing fungal infections [21]. In addition, glucocorticoid treatment (our patient was taking for arthritis) inhibits inflammatory molecules like adhesion molecules, cytokines, and chemokines that aid in the immune system's response to pathogens [22].…”

Biofilms possibly harbor occult SARS-CoV-2 may explain lung cavity, re-positive and long-term positive results

“…Characteristics of cases that SARS-CoV-2 co-infects with other pathogens include venerable age, glucocorticoid therapy, immunocompromised state, long-term antibiotic use history, diabetes, cardiovascular comorbidities, intensive care unit attending, ventilation treatment, prolonged hospitalization time, and exacerbation of symptoms ( Bao et al., 2020 ; Blasco et al., 2020 ; Contou et al., 2020 ; Wang et al., 2020a ; Alhumaid et al., 2021 ; He et al., 2021 ; Yasmin et al., 2021 ; Gomes et al., 2022 ; Hedberg et al., 2022 ; Ortega-Pena et al., 2022 ; Rouze et al., 2022 ; SeyedAlinaghi et al., 2022 ; Shetty et al., 2022 ). Bacterial pathogens generally isolated cover M. pneumoniae , P. aeruginosa , H. influenzae , K. pneumoniae and S. pneumoniae ( Lansbury et al., 2020 ).…”

“…Abundant cases of SARS-CoV-2 co-infection with other microorganisms have been reported, which were associated with venerable age, immunosuppression, cardiovascular disease, diabetes, intensive care unit attending, mechanical ventilation treatment, long-term antibiotic use, glucocorticoid therapy, prolonged hospitalization, exacerbation of symptoms, and poor prognosis ( Bao et al., 2020 ; Blasco et al., 2020 ; Contou et al., 2020 ; Wang et al., 2020a ; Alhumaid et al., 2021 ; He et al., 2021 ; Yasmin et al., 2021 ; Gomes et al., 2022 ; Hedberg et al., 2022 ; Ortega-Pena et al., 2022 ; Rouze et al., 2022 ; SeyedAlinaghi et al., 2022 ; Shetty et al., 2022 ). M. pneumoniae , P. aeruginosa , H. influenzae , and K. pneumoniae are bacterial co-pathogens usually detected ( Lansbury et al., 2020 ).…”